Olecranon Bursitis

Inflammation of the subcutaneous olecranon bursa over the point of the elbow. It is the commonest superficial bursitis, because the bursa lies directly under the skin with little protection.

• Aseptic forms:
  • Traumatic: a single blow or repeated pressure and friction (leaning on the elbow at a desk, students, plumbers, mechanics, miners, and gardeners).
  • Inflammatory or crystal induced: gout (the commonest crystal cause, and may be the first sign), calcium pyrophosphate deposition, rheumatoid arthritis, psoriatic arthritis, and uraemia, with hydroxyapatite less often.
  • Idiopathic.
• Septic bursitis accounts for about 20% of cases. It is caused by Staphylococcus aureus in 80 to 90% (including MRSA), then streptococci, and rarely Gram negative organisms, mycobacteria and fungi. Entry is through a wound, abrasion, insect bite, injection or by haematogenous spread. Risk factors: manual labour, diabetes, alcohol misuse, immunosuppression (corticosteroids, HIV, malignancy), chronic kidney disease, and previous steroid injection.
• It affects men more than women (about 3 to 1) and is most common in the third to sixth decades.

• A fluctuant, boggy swelling over the tip of the elbow, from a few millimetres to a golf ball size or larger. Elbow movement is usually full and painless, because the joint is not involved.
• Aseptic bursitis: swelling with mild or no pain, no warmth, no fever. Gouty bursitis may be warm, red and painful, with tophi on the extensor surface of the forearm and ear.
• Septic bursitis: warmth, erythema, severe tenderness, spreading cellulitis, pain with palpation, limited flexion because of pain, fever in about 50%, regional lymphadenopathy, and a break in the skin or puncture mark. Pain on passive range of motion of the joint (especially pain at the end of flexion) suggests septic arthritis, not bursitis.
• Differential diagnosis: septic arthritis of the elbow (the whole joint is hot, with pain in all directions of movement, joint effusion, and loss of motion), cellulitis without bursitis, olecranon fracture, gouty tophus, rheumatoid nodule, lipoma, ganglion, synovial cyst, haematoma, osteomyelitis, tuberculosis, and a tumour (sarcoma, metastasis).
• Complications: chronic bursitis with a thickened bursal wall, recurrent effusion, bursal fistula or chronic draining sinus, spread to joint or bone (septic arthritis, osteomyelitis), sepsis, and in the immunosuppressed, necrotising infection.

• Clinical, and an essential step is separating septic from aseptic bursitis, because management differs.
• Aspirate the bursa (with an 18 to 21 gauge needle, from a non-inflamed skin site, with a Z-track or oblique approach to reduce sinus formation) when infection is suspected, when the diagnosis is unclear, or when there is a significant effusion with pain. Examine the fluid:
  • Appearance: clear straw yellow (aseptic), turbid, purulent or blood stained (septic, traumatic or inflammatory).
  • White cell count: below 1000 cells/mm3 (non-inflammatory), 1000 to 10,000 (inflammatory), above 10,000 (suggests septic, though many septic cases have lower counts). Neutrophils above 50% suggest infection.
  • Gram stain (positive in about 50%), culture (aerobic and anaerobic, with mycobacterial and fungal cultures if indolent), crystal analysis (needle shaped negatively birefringent monosodium urate, rhomboid positively birefringent calcium pyrophosphate), and fluid glucose and protein (supportive only).
• Blood tests: full blood count, CRP, ESR, urate, creatinine, glucose or HbA1c. Blood cultures if febrile or septic.
• X-ray of the elbow for fracture, spur, calcification, foreign body or bone destruction. Ultrasound confirms a superficial bursa, guides aspiration, and detects tophi and gas. MRI if osteomyelitis, septic arthritis or tumour is suspected.
• Look for inflammatory disease (rheumatoid factor, anti-CCP antibodies, HLA-B27, and psoriasis) in recurrent or bilateral cases.

• Aseptic bursitis:
  • Remove the cause: avoid leaning on the elbow, use a soft elbow pad, and alter work posture.
  • Compression bandage (elastic wrap, not too tight) and elbow pad for 2 to 3 weeks.
  • Ice 10 to 15 minutes, 3 times daily, in the first days.
  • NSAIDs for 1 to 2 weeks: ibuprofen 400 mg orally 8 hourly with food, naproxen 500 mg 12 hourly, or diclofenac 50 mg 8 hourly, with gastroprotection where needed. Topical diclofenac 1% gel 2 to 4 g 3 to 4 times daily is an alternative.
  • Most resolve in 4 to 8 weeks. Aspiration is not routinely needed for a small bursa.
  • Aspiration of large, painful or functionally limiting bursae (with a compression dressing afterwards), keeping in mind that fluid often re-accumulates in 1 to 3 weeks and repeated aspiration risks introducing infection.
  • Corticosteroid injection is controversial and generally avoided because of risks of infection, skin atrophy and chronic pain at the elbow tip (a site where atrophy is troublesome). If used in refractory, clearly aseptic, non-gouty disease: triamcinolone acetonide 10 to 20 mg (or methylprednisolone 20 mg) after aspiration, with strict asepsis. Symptoms usually settle with less risk by compression alone.
  • Gout: colchicine 500 micrograms orally 8 to 12 hourly (maximum 1.5 mg per day in a flare, reduce in renal impairment) or prednisolone 30 to 40 mg daily for 5 days, in addition to the measures listed here, then urate lowering therapy (allopurinol 100 mg daily, titrated by 100 mg every 2 to 4 weeks to serum urate below 360 micromol/L, with colchicine 500 micrograms once or twice daily prophylaxis for 3 to 6 months). Treat rheumatoid or psoriatic disease with the usual disease modifying drugs, under rheumatology.
• Septic bursitis (empirical treatment started after aspiration):
  • Outpatient (mild, without sepsis, in a reliable patient): flucloxacillin 500 mg to 1 g orally 6 hourly, or cefalexin 500 mg orally 6 hourly, for 10 to 14 days (14 to 21 days in immunosuppressed patients). In penicillin allergy: clindamycin 300 to 450 mg orally 8 hourly. If MRSA risk or local prevalence is high: co-trimoxazole 160/800 mg, 2 tablets 12 hourly, or doxycycline 100 mg 12 hourly, with or without rifampicin 300 mg 12 hourly.
  • Inpatient (fever, spreading cellulitis, immunosuppression, diabetes, failure of oral therapy, or inability to take oral medicines): flucloxacillin 2 g IV 6 hourly or cefazolin 2 g IV 8 hourly, adding vancomycin 15 to 20 mg/kg IV 8 to 12 hourly (adjusted to levels) when MRSA is possible. Switch to oral therapy after 3 to 5 days of clinical improvement, for a total of 2 to 3 weeks.
  • Drain repeatedly by needle aspiration (daily or every other day) until the fluid reduces, or perform incision and drainage for loculated or purulent collections, with an immobilising splint or sling for comfort for a few days, then early movement.
  • Surgical bursectomy (open or endoscopic) for failure after 3 to 7 days of appropriate therapy, a thickened chronic bursa, recurrent infection, chronic sinus, necrotic tissue, or suspected osteomyelitis. The bursectomy wound heals in 2 to 4 weeks, with compression and splinting.
  • Tetanus prophylaxis if there is a skin wound, according to immunisation status.
• Chronic or recurrent bursitis: evaluate for causes (gout, rheumatoid disease), protect the elbow, and consider elective bursectomy for persistent symptoms (3 to 6 months), with about 90% good outcome and a small risk of wound problems and a tender scar.
• Special groups:
  • Diabetes: control glucose tightly, start antibiotics early, and have a low threshold to admit.
  • Immunosuppression: prolong antibiotic therapy, and cover MRSA early.
  • Renal impairment: reduce doses of colchicine, allopurinol, NSAIDs (avoid), and vancomycin.
  • Pregnancy: use compression, padding and paracetamol. Avoid NSAIDs after 20 weeks. Cefalexin and flucloxacillin are used for septic bursitis, and avoid doxycycline and co-trimoxazole.
  • Anticoagulation: aspirate with a fine needle and compress for 10 minutes.
• Follow up: review within 48 to 72 hours for septic bursitis, then weekly until healed. Refer to orthopaedics for bursectomy or if septic arthritis is suspected, and to rheumatology for recurrent disease or an inflammatory cause.